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Optimal dosing of angiotensin-converting enzyme inhibitors and β-blockers for acute coronary syndrome: up-titration remains a challenge
  1. Natasha Sharma,
  2. Rani Khatib,
  3. Nadir Elamin,
  4. James Eaden,
  5. Chiat Ee Choong,
  6. Chris Jones,
  7. Muzahir Tayebjee
  1. Department of Cardiology, Leeds General Infirmary, Leeds, UK
  1. Correspondence to Dr Natasha Sharma, 7 Heath Avenue, Halifax, West Yorkshire HX3 0EA, UK; sharms{at}


Objectives Suboptimal dosing of angiotensin-converting enzyme inhibitors and β-blockers limits the mortality benefit for acute coronary syndrome patients. Recent National Institute for Health and Care Excellence (NICE) guidelines emphasise prompt initiation and up-titration from inpatient to community care to achieve this. The aim of this study was to assess the impact of simple interventions on inpatient and community up-titration of bisoprolol and ramipril for acute coronary syndrome patients admitted to Leeds General Infirmary.

Methods An initial prospective audit of 37 acute coronary syndrome patients admitted to Leeds General Infirmary in January 2013 assessed inpatient up-titration of bisoprolol and ramipril, discharge advice and doses at 6 weeks after discharge. Following a collective multidisciplinary effort with education, posters and discharge advice templates, a re-audit of 34 acute coronary syndrome patients admitted from November to December 2014 assessed the impact of these interventions. The independent samples t test was used to compare the mean difference between doses of ramipril and bisoprolol from initiation to discharge to dose at 6 weeks after discharge before and after intervention.

Results There was a statistically significant improvement in the mean difference from initiation to discharge dose for both ramipril and bisoprolol (p=0.012 and p=0.017, respectively). However, there was little difference in community up-titration despite a 68% improvement in discharge advice.

Conclusions Simple multidisciplinary interventions improved inpatient up-titration of ramipril and bisoprolol but continued up-titration to achieve the target doses remains a challenge in primary care. Acute coronary syndrome patients are precluded from maximum mortality benefit due to suboptimal dosing after discharge.

  • acute coronary syndrome
  • beta-blocker
  • angiotensin-converting enzyme inhibitor
  • up-titration
  • medicines optimisation

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